Provider Demographics
NPI:1942308473
Name:PETTIT, WILLIAM ALFRED III (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALFRED
Last Name:PETTIT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1404 GEKELER LANE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850
Mailing Address - Country:US
Mailing Address - Phone:541-963-3119
Mailing Address - Fax:541-963-3110
Practice Address - Street 1:1404 GEKELER LANE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-3119
Practice Address - Fax:541-963-3110
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17635207W00000X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044607Medicaid
F31486Medicare UPIN
OR0000BKFPSMedicare ID - Type Unspecified